Rezapour, M., & Stollman, N. (2018). Antibiotics in Uncomplicated Acute Diverticulitis: To Give or Not to Give?. Inflammatory intestinal diseases, 3(2), 75–79. https://doi.org/10.1159/000489631

Data review of RCT’s

Acute uncomplicated diverticulitis (AUD) is generally felt to be caused by obstruction and inflammation of a colonic diverticulum and occurs in about 4–5% of patients with diverticulosis. The cornerstone of AUD treatment has conventionally been antibiotic therapy, but with a paradigm shift in the underlying pathogenesis of the disease from bacterial infection to more of an inflammatory process, as well as concerns about antibiotic overuse, this dogma has recently been questioned. We will review emerging data that supports more selective antibiotic use in this population, as well as newer guidelines that advocate this position as well. While there are no discrete algorithms to guide us, we will attempt to suggest clinical scenarios where antibiotics may reasonably be withheld.

• Data review of  randomized controlled trials
•  1^st trial found no statistical differences In those treated with antibiotics and those not treated with antibiotics. Assessment based on complications, frequency of surgery,  length of hospital stay, recurrence of diverticulitis, abdominal pain, or changes in bowel habit.
• 2^nd trial found no significant differences between observational group and antibiotic treatment group. Hospital length of stays was significantly shorter in the observational group than in the antibiotic group. The author suggested that antibiotics should not be used in patients with “first episode of uncomplicated, left-sided acute diverticulitis”.
• Studies showed support of treating acute uncomplicated diverticulitis with non-antibiotic therapies.  European guidelines and American Gastroenterological Association Institute guidelines advocated for selective use of antibiotics rather than routine use.

I chose this article because thought the RCT’s were non-USA based, the data review of them was conducted in California (non-foreign). The review also looked at RCT’s which are of high validity and eliminate bias and allow for optimal randomization. The elements that were being evaluated in the RCT’s also matched the PICO search elements I included (frequency of surgery, recurrence of diverticulitis, and length of hospital stay, complications, and changes in bowel habits are directly associated with symptom resolution. It was a fitting article for my PICO research and helped me gather evidence that would further evaluate my research question.

Smolarz, C. M., Hohertz, B., & Seupaul, R. A. (2014). Are antibiotics required for the treatment of= uncomplicated diverticulitis? Annals of Emergency Medicine, 63(1), 52–53.

Systematic review of RTC’s

Methods:

Data Sources- The authors searched The Cochrane Library (including CENTRAL), MEDLINE (1948 to March 2011), EMBASE (1980 to 2011), and Current Controlled Trials (controlledtrials.com). Additional studies were sought by searching reference lists of relevant randomized controlled trials.

Study Selections- Only randomized controlled trials of uncomplicated left-sided diverticulitis in adults comparing antibiotics to placebo, other antibiotics, or standard practice were included. The diagnosis of diverticulitis had to be confirmed by computed tomography, ultrasonography, or contrast enema. The primary outcomes, defined by the study authors, were complication rate (abscess, fistula, stricture, or perforation with peritonitis or sepsis) and emergency surgery rate.

Data Extraction & Synthesis- Quality of study methodology was assessed according to the Cochrane Collaboration’s Tool for assessing the risk of bias. A qualitative analysis of included trials was performed because of a high degree of heterogeneity.

Take-Home Message: Limited data (1 randomized trial) suggest that antibiotics may be no better than placebo for the treatment of uncomplicated diverticulitis. More randomized trial data are required to help define the best therapeutic option.

•  USA based data review that was performed only including RCT’s
• Of the 3 studies used, 2 compared antibiotics to a placebo and the third compared two different types of antibiotics.
• Methods of evaluation were complication rate (abscess, fistula, stricture, or perforation) as well as the need for emergency surgery.
• No statistical differences were found in the studies.

The main reason I chose this article was that it is a USA based article. With the prognosis and diagnosis of diverticulitis being heavily influenced by ones diet, I thought having a USA study was of high importance since diets drastically differ in other countries. I also thought the article not only discussed placebo vs antibiotics but also the efficacy of different antibiotics. This made me further interested in the treatment of diverticulitis and if better results were associated with one antibiotic vs another which is a potential follow up PICO research topic I can examine. Emergency surgery was also being assessed as an evaluation criterion which was one of my PICO elements. Complications that are listed are also directly associated to resolution of symptoms which is another one of my elements.

Chabok, A., Påhlman, L., Hjern, F., Haapaniemi, S., Smedh, K., & AVOD Study Group (2012). Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. The British journal of surgery, 99(4), 532–539. https://doi.org/10.1002/bjs.8688

Randomized trial

Background: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.

Methods: This multicenter randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.

Results: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881).

Conclusion: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

• Randomized controlled trial involving ten surgical departments in Sweden and one in Iceland. 623 patients with CT verified acute uncomplicated left-sided diverticulitis. 314 treated with antibiotics and 309 without.
• Short term methods of evaluation included occurrence of complications, need for surgery, length of hospital stay, abdominal pain (symptom), fever (symptom), and abdominal tenderness. Long term methods of evaluation included recurrence, need for surgery, changes in bowel habits (symptom), abdominal pain (symptom),  and results of colorectal examinations.
• Results showed no significant differences between patients treated with antibiotics in terms of recovery time and reduction of complications than those not treated with antibiotics at 12 month follow up.

Even though this article was a foreign article, I was limited with the amount of USA based articles existed. I thought this article should be included as it was a RCT which limited any bias and was a large study incorporating data from ten surgical departments. Having a large study further validifies the study and results. I also picked this study because it incorporated all aspects of my PICO elements. It included acute uncomplicated diverticulitis, antibiotic treatment vs non antibiotic treatment, and had similar outcomes that I was looking to evaluate (recurrence, symptoms, and need for surgery). Though it was not a USA based study, I felt it greatly contributed to my research as it was a well detailed organized performed study.